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Abstract

Introduction

Tobacco cigarette smoking a well-known cause of cancer and other diseases. Hookah
smoking is another form of tobacco use that has rapidly spread in the United State
and Europe. This study assessed beliefs about the harmfulness of smoking hookah.

Methods

We surveyed hookah users in all cafes that provided hookah to its customers in downtown
San Diego, California and nearby areas. A total of 235 hookah users participated in
this study.

Results

Average age of study participants was 22 years, 57% were males, and 72% were not cigarette
smokers. Whites were more likely to use hookah than the other ethnic groups (33%),
older hookah users (26-35 years) were mostly males, and mint flavor of hookah tobacco
was the most popular among a wide variety of flavors (23%). There was no significant
difference in gender in relation to the wrong perception that hookah is less harmful
than cigarettes, but those of Asian ethnicity were much less likely than other ethnic
groups to believe that hookah is less harmful than cigarettes. More frequent users
of hookah were more likely to believe that hookah is less harmful than cigarettes.
The majority of hookah users (58.3%) believe hookah is less harmful than cigarette
smoking.

Discussion

Compared to cigarettes, there appears to be a lack of knowledge about the harmfulness
of smoking hookah among users regardless of their demographic background. Education
about the harmfulness of smoking hookah and policies to limit its use should be implemented
to prevent the spread of this new form of tobacco use.

Introduction

Lung cancer is the leading cause of cancer mortality in the world [1]. Cigarette smoking cause up to 87% of lung cancer deaths worldwide and is estimated
to cause up to 90% of lung cancers in the United States [2-4]. Smoking is also responsible for cancers of larynx, oral cavity, pharynx, esophagus,
and bladder [4,5]. Moreover, continued smoking increases resistance to cancer therapy in lung cancer
patients [6,7]. The smoke from tobacco contains more than 60 carcinogens of both radioisotopes and
chemicals [8] that in additional to cancer can cause several respiratory ailments and increase
in respiratory infections. Nicotine contained in cigarette smoke causes a depression
in the immune response to malignant growths in exposed tissue [9].

Hookah smoking is another form of tobacco use. Hookahs originated in India in the
15th century and then spread to the Near East countries. Hookahs spread first to Persia
and underwent further changes to its original shape to the current known shape. In
the middle of the 16th century, hookahs reached the Ottoman Empire, Egypt, and other Mediterranean regions
[10]. Late in the 19th century, hookah use started spreading among women in the Middle East [11,12]. In the last two decades, the use of hookah has been gradually increasing in Europe
and the USA [13-16]. Hookahs are known around the world by many different names and slightly different
forms: water pipe, hubble-bubble, nargeela, nargileh, argeela, arghileh, shisha, sheesha,
okka, kalian, ghelyoon, ghalyan, boury, and gouza. Originally, the tobacco smoked
in hookahs did not have any additives, but lately, the "Ma'ssell" was introduced,
which is a mixture of tobacco, molasses, and often a flavor or fruit extract. Adding
fruit to hookah base provides more flavors. The smell of the smoke-flavored tobacco,
social ambiance with friends and family, and easy access to hookahs are some of the
factors attributed to its dramatic spread. Different methods of providing hookahs
in cafe lounges with coffee or other drinks and the ability of the user to handle
the charcoals for the hookah gives the practice a special culture that is probably
helping hookah spread and popularity [17].

Some perceive hookah is not harmful [18-21] because of the belief that the smoke gets filtered in the water [22,23], but it is not clear if this perception is widespread or different according to demographic
and population characteristics. Scientific facts indicate that when compared to cigarette
smoking, the number of puffs and volume from using hookahs are about ten times higher
than cigarettes [19,24]. Hookah smoke also contains 36 times the amount of nicotine and higher concentrations
of heavy metals [24,25]. The burning temperature of tobacco for hookah use is about 900°, compared to 450°
for cigarettes, which could produce different type and levels of harmful chemicals
and tar [24]. Further, exhaled CO levels from hookah users were twice as high as cigarette smokers
in cessation programs [21]. Like cigarettes, hookah use is also a health hazard to non-smokers because of secondhand
smoke and it can lead to the transmission of infectious diseases, since the same hookah
mouthpiece can be used by many people during the same smoking session [26-28]. Hookah use has been shown to cause an acute increase in heart rate and systolic
and diastolic blood pressure [29]. Studies have shown that using the water as a filter in the hookah did not change
the level of nicotine in the smoke compared to that without using the water [24,30].

Data on the perception of risk of hookah use compared to that of cigarettes are limited
and vary from one region to another. Because of current rapid increases in hookah
use in the US, more data are needed about those who use it and their perceptions.
Previous studies about hookah use in the United States involved Internet surveys,
university students [20,31,32] or the military [18]. Two studies specifically surveyed hookah users in the US. One study was limited
to a single cafe in Richmond, Virginia and a sample from an Internet hookah forum
[17]. Participants in the second study were recruited via flyers that were distributed
in two cities (Richmond, VA and Memphis, TN), and participants were interviewed in
a lab setting [33]. Participants in both studies were paid volunteers. In this study, a survey of hookah
users from hookah cafes in San Diego, California was performed to assess characteristics
and perceptions of users in the general population in Southern California in relation
to the believe about hookah smoking harmfulness. Knowing the characteristics of the
hookah users according to their belief about harmfulness of smoke from hookah tobacco
would help develop health promotion initiatives and interventions that specifically
address the sub-population of users who need it most.

Methods

An Internet search was made for any venue providing hookah smoking within San Diego.
These were mapped and all the venues of restaurants, cafes, and clubs located geographically
in downtown and up to 15 miles in any direction were included. Venues that did not
match these criteria were contacted and asked about serving hookah smoking and places
that only sold hookah paraphernalia and related tobacco products were excluded. Participants
were those who were smoking hookahs in these venues at the time of data collection.
Data were collected from nearly all cafes that offered hookahs lounge in downtown
San Diego, California and the surrounding suburb area.

Data was collected during a four-week period in August and September 2008 during the
weekdays and on weekends. Most collection occurred on Friday and Saturday nights because
of the large number of hookah smokers available during these periods. Owners of the
10 venues selected for this study were initially approached to obtain their permission
and all of the owners agreed to allow the survey to be conducted. After obtaining
verbal approval from the hookah users, we then asked them to sign a consent form and
fill in the questionnaire. Similarly, there was a very high response rate among hookah
users approached for the survey; only one person refused to participate. All participants
sitting in the cafes were given the surveys unless they said they did not smoke hookah.
A total of 256 persons participated in this study; 21 people from this group were
excluded because they stated in the survey that they were non-hookah users. Some of
them requested to complete the survey even though they did not smoke hookah.

Questionnaires

The survey was brief, since longer surveys can disrupt a business and lead to a poor
response rate from customers who want to enjoy their time. Questions were included
about the participant's gender, ethnicity, and age. In order to assess the association
between cigarette and hookah smoking, participants were asked about cigarette smoking,
number of cigarettes smoked a day and brand of cigarettes. Hookah users were asked
for their favorite hookah tobacco flavor, and how often they smoked hookah. The final
question assessed their opinion about the harmfulness of hookah smoking compared to
cigarette smoking.

Data analysis

Descriptive analyses of means, medians and percentages were calculated for the variables
in this study. Data from the questionnaire were categorized for the purpose of analyses.
We also carried out analyses by gender. The different cigarette brand and hookah flavor
were assigned as "Other" if only 3 or less participants reported them. Age was dichotomized
at the median of 25 years. A chi-square test was carried out on categorized variables
to determine the level of significance between the different variables of the study.

We initially assessed the harmfulness perception of smoking hookah according to characteristics
of our study population and determined significance using a chi-square test. Any participant
who did not answer the question about harmfulness was not included in the final analyses.

Results

Details of participant demographics and their beliefs about hookah use are described
in Table 1. Out of 235 participants, 57% were males. White participants represented 32.9% of
the study subjects, followed by Latino (22.4%), Middle Eastern (21.5%), Asian (11.0%),
and African American (6.6%) ethnicities. The average age of participant was 21.8 years.
Among all participants, only 28.4% were cigarettes smokers, with a median number of
cigarettes smoked per day of 6 cigarettes. Most of the cigarette smokers smoked the
Camel brand. A total of 35.2% of hookah users smoke every week and a smaller percentage
(27%) smoke every 6 months, every month (24.4%) and every day (13.5%).

Frequencies of reported favorite hookah flavors are shown in Figure 1. Mint flavor seems to be the most common-used flavor and was chosen by 22% of our
study subjects. Individual fruit flavors as the favorite flavor for individuals were
mostly less than 5%, while a larger percentage of participants (19%) preferred a combination
of fruit flavors.

Figure 1.Frequencies of reported favorite tobacco flavor in hookahs among users in San Diego.

Characteristics of participants by gender are described in Table 2. There was no significant difference in the ethnicity according to gender. Whites
were more frequent users of hookah, followed by Middle Eastern and Latino participants
in both genders. Most males and females were non-cigarette smokers. Age was different
between males and females, where more females were in the younger age group than males
(p = 0.02). Females were less likely than males to smoke hookah every day and more
likely to smoke every 6 months, although this did not reach statistical significance.

A majority of hookah users (58.3%) believe hookahs are less harmful than cigarettes
and only 30.4% believe they are more harmful than cigarettes. Belief about harmfulness
of smoking hookahs compared to cigarettes was very similar between males and females.
Participants' beliefs about the risk associated with hookah smoking compared to cigarettes
are shown according to their characteristics in Table 3. There was no significant difference in belief of harmfulness of smoking hookah according
to smoking status (p = 0.58), frequency of hookah use (p = 0.55), or age (p = 0.84).
Only ethnic groups were statistically significant in their perception and belief about
the harmfulness of hookah smoking. Whites, African Americans and Middle Eastern ethnic
groups were much more likely than Asians and slightly more than Latinos to believe
hookah is less harmful than cigarettes (p = 0.03).

Table 3. Hookah user belief on the harmfulness of hookah smoking by characteristics.

Using logistic multivariate regression analyses to predict the belief that hookah
is less harmful vs. same as or more harmful than cigarettes, none of the variables
were significantly related to such belief when put in the model (data not shown).

Discussion

Our study suggests there is a widespread perception among hookah users that it is
less harmful than cigarette smoking and it is independent of gender, ethnicity, age
or smoking status of users. Our population-based study of hookah-bar patrons in San
Diego included all hookah bars in the downtown area and surveyed patrons from different
ethnic groups and both genders. Hookah users were mostly young men and women below
the age of 25 years.

The percentage of smokers in our study population of hookah users was 28.4%, which
is higher than the 13-16% smoking prevalence in the general California population
for those aged 18-44 years [34]. However, smoking prevalence among hookah users in our study was very comparable
to that in the general California population as represented by the California Tobacco
Survey; which is a State-wide survey of a representative population from California
that found that 30.6% of hookah users were current smokers in 2008, which is the same
year the current study was conducted. Therefore, our study sample of hookah users
resembles the larger California population in terms of smoking prevalence.

It therefore appears that hookah smokers are more likely to be cigarettes smokers.
This was also found in other studies from US cities, although the cigarette smoking
rates for hookah users varied widely, from 63% in Richmond, VA [33] to 58% in Pittsburg, PA [20] and 35% in Memphis, TN [33]. This may reflect the difference in sampling from web-based and volunteer study subjects
to random university sample compared to hookah café users in our study. This could
also be explained by the difference in the population of hookah users between regions
in the US. This difference is important to document and understand for the purpose
of determining future hookah control programs and initiatives.

A study from the United Kingdom found cigarette smoking was the most important predictor
among those who ever tried hookahs to become regular hookah users [21]. In our study, smoking cigarettes did not significantly influence the belief that
hookah is less harmful than cigarettes; a majority of hookah users believed it was
less harmful than cigarette smoking. Recent smaller studies from different US populations
confirm this misperception [17,20,31-33]. A qualitative analyses of attitudes among 12 hookah users in the UK and Canada also
support the perception among users that hookah use is less harmful than cigarettes
[35].

Perception that the hookah smoke is filtered in the water seems to be one the main
beliefs justifying the less harmful influence of hookahs [22,23]. However, it is well known that passing air bubbles through water does not change
their contents, and since the volatile carcinogens for tobacco smoke and other particles
will stay within the air bubble during its passage through the water, the water will
not filter the smoke in the bubbles. Some hookah users report hookah smoke being less
irritating than cigarette smoking, noting it has a 'smooth texture' that allows them
to smoke it for hours [35]. More importantly, the negative social norm against cigarette smoking is not applied
to hookah because of its more recent trend and use. This may be contributing to the
wide and dramatic spread of this type of tobacco use.

It is a public health concern that non-cigarette smokers believe that hookahs are
less harmful than cigarette use because those who did not smoke until becoming adults
passed the period of adolescence and early adulthood when they are most vulnerable
to cigarette smoking. This group may be reintroduced to the habit of cigarette smoking
through hookah use or continue to be regular hookah users and get exposed to the harms
of tobacco use. In conducting this study, there were several friends of hookah users
who were sitting at the same table in the hookah café but reported never smoking a
hookah. Given that previous studies show most of the hookah users started with friends
in café restaurants [17,33] and since this has mostly become a group socializing activity, we believe those nonsmokers
will eventually try a hookah and become users along with their friends.

Higher frequency of hookah use was positively related to the belief that it is less
harmful than cigarettes; 70% of every-day hookah users believe it is less harmful
than cigarettes while only 50% of those who use it every six months believe it is
less harmful than cigarettes. This did not reach statistical significance. This suggests
that there is a risk that irregular users will gradually become regular more frequent
users based on their belief this will not be as harmful to their health.

Our ethnic distribution of Latinos, Asians and African Americans were demographically
comparable to that for California, but there were less Whites and a much higher Middle
Eastern ethnic group in our study sample. Middle Eastern ethnicity is usually categorized
as White in the general census. The much higher use by the Middle Eastern ethnic group
was also found in a study in the UK, where they were twice as likely to use hookah
than other ethnic groups [21].

Another observation we noted during data collection was a tendency for similar ethnicities
to frequent the same hookah bars. This is part of the appeal of hookah use, as a social
group activity for people with similar backgrounds. In addition, the exotic relaxed
atmosphere, the nice sweetened scents from the flavored hookah tobacco smoke, and
the relatively cheap costs of smoking a hookah contribute to its use among mostly
young adults [26]. Asians in our sample were significantly more likely to believe a hookah is more
harmful than cigarettes. However, this was not significant in the multivariate analyses
and may be due to the small number of subjects in this group. Further exploration
of this finding is needed from future studies. Other comparable studies in the US
mostly included White ethnic groups.

There was no influence of gender on the perceptions and use of hookah from our study.
The hookah originated in Asia and its use for many decades in recent history was dominated
by males. However, re-birth of this habit in modern age among young adults in the
Middle East is spreading among females [11,16,26,36,37] due to social acceptability even in traditionally conservative societies like Saudi
Arabia. Previous studies in the US show a large variation in participation of hookah
users according to gender [17,20,33].

Mint flavor is the highest single hookah tobacco flavor preferred by users in our
study. This flavor has also been popular in the US by smokeless tobacco and cigarette
users Outside the US, it is not known which flavors predominate. The numerous varieties
of flavors and the fact the most users used or preferred all flavors suggest a risk
for continued use and exploration by users of the different flavors of tobacco.

Our study is one of the larger studies in the United States that addresses characteristics
of hookah users by targeting them in the general population as café patrons. Previous
studies recruited volunteers who were provided incentives for volunteering. Although
our study is not a random representative sample of hookah users, the fact that all
major hookah cafes were included gives some confidence about the representativeness
of such users. Some San Diego cafes that do not have a web address or are not listed
on the Internet might have been missed, but this is unlikely, since the majority of
businesses are on the Internet and list web sites for the hookah bars. We are not
able to comment on users who exclusively smoke at home; those users may be underage
teens. The short questionnaire prevented in-depth exploration of attitudes and behaviors
about hookah use. However, this was not a qualitative analyses and the aim was to
assess the characteristics and perceptions of hookah café patrons.

In conclusion, we found a concerning trend of emerging use of hookah and the belief
that it is less harmful than cigarette use. Most of the hookah users were non-cigarette
smokers. Both current smokers and nonsmokers had comparable views and therefore there
is a risk that this will become a new tobacco use trend for never smokers. The exotic,
social, and group nature of this habit is appealing to young adults, regardless of
gender or ethnicity. Middle Eastern ethnicity seems to be the most vulnerable group
for hookah use. Culturally-targeted public health campaigns to educate and disseminate
to the younger population about the harmful effects of hookah are urgently needed.
Health policy initiatives should be formulated to prevent marketing and licensing
of hookah tobacco products and paraphernalia in local markets and shops. Further studies
on the spread of hookah use among underage teens who are unlikely to frequent the
hookah bars are needed. We also believe future studies should directly quantify the
harmfulness of hookah smoking by determining pulmonary and other vital functions among
users.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

KJ helped design the study, carried out data collection, data analysis, and drafted
the manuscript. ZQA carried out the statistical analysis and interpretation. WKA conceived
the study, supervised the data collection and analyses, and helped draft the manuscript.
All authors read and approved the final manuscript.

Acknowledgements

The authors wish to thank Janice Jones for assistance in database management and Chris
Hayes for editorial comments. Wael Al-Delaimy was partly supported by grant # 12548
from the Flight Attendants Medical Research Institute.

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